"Stupid is...stupid does."

I have come to the conclusion that trauma patients are sometimes the dumbest patients. Here is a sample of some of the geniuses that roll through our doors. Those who attempt suicide and are unsuccessful are notorious for not really thinking it through very thoroughly. We have three patients right now that are failed suicides. One of them jumped from a third story window and hit every balcony on the way down. She didn't die but did break every bone in her body from the femurs down. Another guy shot himself in the face but didn't point the gun at the right angle to do any fatal damage. He shot a hole through his tongue up through the roof of his mouth and out his mastoid (the bone behind your ear). He underwent plastic surgery last night on his tongue to put it back together again. He is now intubated but not because his brain isn't working , it's because his tongue is so swollen that it blocks his airway. Our other suicidal man also shot himself in the head. He put the gun up to his temple and pulled the trigger. He didn't have the correct angle either. This guy blew out his orbit and made a trail under his nasal bone and out above his teeth. All of these long term hospitalizations could have been avoided if they had just studied a little anatomy and physics.

Another one of our overachievers decided to run away from the cops early this morning and they let the dogs loose on him. He found out first hand just how strong the jaws of a German Sheppard are, strong enough to break your tibia and fibula. Now he needs surgery to reassemble his leg. He will heal up just in time to go to the dauphin county prison. Another one of the cities finest citizens decided it would be a good idea to shoot at the SWAT team with whom he was engaged in a standoff. They of course filled his body with 11 bullet holes. Amazingly none of them hit any vital organs and damaged them enough to kill him.

And then of course we have more than our fair share of motorcycle accidents without helmets. I saw a 45 year old woman today who was the passenger on a motorcycle and was not wearing a helmet. By the grace of God she did do any brain damage. She broke her tibia and fibula, her scapula, and 5th metacarpal. That wasn't the bad part. Her face looks like it belongs on the shoulders of a sumo wrestler. Her eyes were so swollen she can't see out of them. Her face was also completely covered in road rash. So now this once pretty woman is going to need skin grafts on her face all because she wouldn't wear a helmet. Stupid, just plain stupid!

This list could go on and on but I'll stop there. Not every trauma patient is there because of something they are responsible for, in fact most of our patients are car accident victims who happened to be in the wrong place at the wrong time. So kids, the moral of the story is don't do anything stupid enough to land in the trauma bay because I may appear sympathetic on the outside but in reality I am shaking my head in disbelief at your stupidity.

Trauma. It's not really my thing.

WARNING: this is a detailed and gruesome encounter of a trauma i saw today!!
I've finished ER and have now moved on to surgery. Instead of doing general surgery I chose to try the trauma surgery route. It's been three days and I have yet to see the inside of an OR. I have however spent more than enough time in the trauma bays. Today was the first time I have ever been in the trauma bay but I made it there three times. Two of them weren't so bad; one was a patient who was run over by a dump truck and drug 40 feet and the other fell from the top of a ladder that was two stories up. Both of these patients had non-life threatening injuries. The first trauma of the day was not quite so "nice." I was hoping my first trauma experience would be something not so intense like the man falling off the ladder but that wasn't the case.

We got the page that a level one trauma was coming in while we were in the middle of rounding. The entire team stopped mid round and ran to the trauma bays. I wasn't sure what to do but the residents were very friendly and helpful and directed me. We all threw on lead and gowned and gloved up. While waiting for the helicopter to land we were briefed on what was coming. It was a 50 y/o male who was driving a mini van and was hit by a tractor trailer. We were told he had bilateral lower extremity crush injuries which resulted in amputations and had coded in the field. We were also told that there was massive blood loss, the paramedic reported seeing 2 inches of blood on the floor of his vehicle while cutting him loose. We knew it was going to be bad. I however did not realize just how bad. The gurney came barreling through the trauma bay doors and the room exploded into chaos! There were around 20 people in the room, everyone of them doing something or looking for something. The attending was barking orders out and the team frantically attempted to follow them as quickly as possible. My eyes immediately landed on the patients mangled legs. His feet were flipped around with his toes pointing towards his back instead of the front like normal. I have never in my life seen that much blood, not even in a horror movie. It was unreal. There was not single person in the room who didn't have blood on them. The patient was in cardiac arrest when he came in so the team worked feverishly to resuscitate him. The patient would get a pulse and a rhythm then two minutes later he would lose it again. This went on for an hour and half. Every ten minutes someone knew would do compressions. You never knew when you were going to be yelled at to do something. It was overwhelming for someone who had never been in a trauma bay let alone seen one of this magnitude. Every single person was doing something different, one guy was intubating, another was putting a central line in, another was putting bilateral chest tubes in, and still another was placing tourniquets on the limbs. We ended up getting a pulse and a rhythm for long enough to transport him to the OR where we could better manage the bleeding. I did not get to go to the OR but later found out that the patient died during surgery from blood loss. When it was all said and done he had received a total of 14 units of packed cells. That's a lot of blood!

After the trauma was over everyone was utterly exhausted. We all turned into zombies for the rest of the day. It is hard to watch that kind of thing and not be affected. You replay the event over and over in your head looking for anything that you could have done better. I was later told that people who sustain crush injuries in car accidents with major blood loss very rarely survive. The battle was lost before it even began. This didn't really make me feel any better. It didn't make it any less horrific. I would be perfectly happy to never see anything like this again. I'm going to have nightmares for the next two weeks. I don't think trauma is my thing. This hospital sees an average of 2-3 traumas of this magnitude per month. This could be a very very long and emotional 6 weeks.

WARNING: This is not a happy feel good post. It's about someone dying, you might not want to read it.

Last week my preceptor and I were talking about things I needed to see and/or do yet before I'm done in the ER. She said I needed to put an NG tube in and I needed to watch somebody die. I thought that last one was a bit morbid but I figured she knew what she was talking about. I've seen and participated in several codes but amazingly they were all brought back and stabilized. I figured that I might get to put an NG tube in someone but I really didn't think I would see someone die. Literally the next day I got my chance.

From what I hear usually when someone dies in the ER there is a flurry of activity with people doing everything they can to save the person. This wasn't the case this time. This patient had liver cancer and was brought in via ambulance because she was bleeding out. The patient had requested that no heroic measures be taken or machines be used to keep her alive. So all we could do was watch and wait for her to pass. That is the hardest part in medicine, watching and waiting. I stood by watching the woman fight for every last breath...every last heart beat...every last second. The look in the woman's eyes when she realized what was happening to her was unforgettable. It was a look of complete terror and panic. I felt helpless standing there. The only thing we could do was give her pain medication to make it a little more tolerable. Slowly, with every passing minute, her pressure continued to fall and her heart rate slowed. Eventually she quit fighting and was overcome with complete peace.

Death is a necessary part of life and unfortunately as clinicians a part of life that we have to get comfortable with. I guess I'm comfortable with death in and of itself but I'm not so sure anyone can ever be okay with actually watching the human body die. Yes it's systematic in nature but you still cannot remove the humanity from it. You realize that this person is suffering and that with every organ system that shuts down that suffering increases until eventually it's over. It's a relief for everyone involved when it's over. That was one of the hardest things I've ever had to watch and sadly it probably won't be the last time I see it.

This was an experience that I will not soon forget.

I apologize ahead of time for this entry. It is going to be a bit of venting and a bit of poking fun at the expense of stupid and or lazy people. I believe the emergency room no longer deserves the title of "emergency room". It should be called the "convenience room." Twenty years ago people only came to the ER if they were either dying, hemorrhaging, or had a limb or appendage severed. This is not the case in today's world. The medical governing bodies, whoever they may be, harp on us for not getting patients in and out of the ER in a timely matter. That is because they are overcrowded by non-emergent riffraff. I've only been doing emergency medicine for four weeks but I have come to loathe these types of patients. I hate picking up a chart and seeing that they are here for an injury that occured 6 years ago. Someone needs to reevaluate the system. I have compiled a list of the top ten reasons for visiting Mercy's ER.

10)A cat scratch
9) A change in mental status but only if you are 93 and have end stage parkinsons.
8) Two mosquito bites.
7) A physical to get into the salvation army's work program. The catch is that you must have just smoked crack before you walk in.
6) "Accidentally" spraying bath and body works inside your vagina.
5) You lost your perscription for vicodin, percocet, morphine, oxycontin, and heroin the minute you walked out the ER door yesterday.
4) An invisible rash that clearly is all over your arms, feet, back and face.
3) You keep thinking that someone is constantly pulling on your "wiener".
2) Unresponsive but you have to be terminally ill, 95 years old, and have a DNR.
1) Chronic back pain for 20 years.

These are all actual chief complaints that I have seen in the ER. A few side notes about those patients, #8 called an ambulance to bring her to the ER to be seen, #6 actually had herpes, and #3 was pulling on his own wiener and didnt know it. Gotta love people.